By a vote of 61-39, the Senate passed the Mikulski Amendment to the Patient Protection and Affordable Care Act today. The Mikulsi Amendment, submitted by Sen. Barbara Mikulski (D-MD), requires all health plans to cover comprehensive women’s preventive care and related screenings, at no additional charge to women. Meaning, basic women’s health care like pelvic exams, mammograms, counseling, testing and treatment for sexually transmitted infections (STIs) and family planning will be available under all insurance plans with limited or no co-pays.

While the question on everyone’s mind is whether or not birth control falls under this list, it seems at the moment there is no clear answer. While contraception is not specifically listed in the amendment, Tait Sye, spokesperson for Planned Parenthood Federation of America tells me,

"It allows Health Resources and Services Administration (HRSA) [editor’s note: the Health and Human Services department developing these guidelines] to recommend what should be covered, so HRSA can/could recommend birth control be covered."

According to a Senate Democratic aide, responding to concerns that birth control is not specifically called-out in the amendment, if individual drugs or "even categories of drugs" were listed, "we would have seen amendments filed on each one (or each category). I trust Sebelius [Kathleen Sebelius, head of HHS] to do the right thing with respect to covering birth control."

Marcia Greenburger, co-President of the National Women’s Law Center is quick to note the impact this will have on low-to-middle income women who opt-out of basic care because of the added costs, even with insurance:

"We are pleased that the first amendment to the Senate’s health care bill will make preventative health care more accessible and affordable for millions of women – some of whom have limited health screenings, not by choice, buy by financial necessity."

The Amendment directs HRSA, under the Department of Health and Human Services (HHS), to set guidelines for exactly which women’s health services would be exempt from co-pays – a sticky issue for Republican senator Lisa Murkowski, from Alaska, whose "alternative" to the Mikulski Amendment is also being voted on today.

Murkowki’s women’s health amendment would allow private insurers to set these same guidelines, deciding which preventive services for women will or won’t be exempt from co-pays. But this is obviously problematic because, as Suzy Khimm writes at The New Republic, "as a for-profit industry, insurers naturally have the incentive to
offer less generous benefit packages that would require customers to
shoulder more out-of-pockets expenses like co-pays."

Women’s health care advocates are naturally thrilled at passage of the Mikulski amendment. Planned Parenthood Federation of America‘s Cecile Richards notes that preventive health care is "life-saving care" and the disparities between what men and women have historically paid for health care costs is huge:

"Women of childbearing age spend 68 percent more in out-of-pocket health care costs than men, in part because of reproductivce health-related needs. It is time that women’s health is made a priority, and providing affordable access to essential care is key…"

She is, of course, right. The "I am Not a Pre-Existing Condition" campaign started by the National Women’s Law Center and taken up by many women’s health and rights advocates, began because of these tremendous disparities and the bias that exists in insurance coverage: lack of coverage of maternity care (including prenatal care and childbirth), exorbitant costs related to childbirth even if covered under one’s insurance plan, the classification of c-sections and miscarriages as "pre-existing conditions" and subsequent denial of coverage for them, and lack of coverage of birth control are just some of the basic health services women have had to pay for out-of-pocket or go without.

"As a physician, I know that preventive care saves lives. Too many women die each year from cancers that could have been detected during an annual well-woman exam."

There are concerns, however, that allowing a government agency to decide these guidelines puts these decisions at the whim of the ideology of a different administration. "I know that there’s legitimate concern as to whether this bill gives such broad
discretion to the Secretary of HHS that under a different administration, we
could be in trouble when it comes to covering birth control, " the Senate aide tells me. "One note on that
— the bill gives the Secretary of HHS authority to define essential health
benefits, which must include the ten general categories of care listed on pg.
103 of the bill."

There are clear parameters for what must be considered, she says.
"In defining the essential health benefits, the Secretary must take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups."

The Mikulski Amendment, however, does not address abortion coverage. By now, regular readers of RH Reality Check know about The Stupak-Pitts Amendment passed in the House health care reform bill, severely restricting private insurance coverage of abortion. Senator Ben Nelson (D-NE) has been working to craft a similar amendment for the Senate health bill, though according to Lindsay Beyerstein, it is unlikely he’s got the votes to get it passed.

Still, as Beyerstein notes, the fight to ensure that health care reform remains "abortion neutral" is long from over. Once the Senate and House put their two bills together, the struggle to pull the U.S. Conference of Catholic Bishops (via anti-choice Democrats and Republicans) anti-choice stamp off of the bill will be difficult.

For now, women in the United States can claim a victory for our health care. Senator Mikulski has succeeded in leveling the playing field for women with private insurance coverage, ensuring that more women in this country are able to access preventive care, getting the health services they need and deserve.

You forgot to mention that the Mikulski amendment could also open the door for HHS to define abortion into the bill and require insurance companies to cover abortions — without copayments even. Or is that not a victory?

amie-newman

There seems to be virtually no way this would "open the door" to having HHS include abortion care in this list of preventive services for women provided for little or no co-payment.

Amie Newman

Managing Editor, RH Reality Check

crowepps

Someone with great personal insight has described this problem:

Many beliefs of our society are outright bizarre, and others are blatantly false. … The belief has truth to our culture, without being true. It has a place in our own webs of significance. When a culture at large believes irrational falsities, it is not psychosis; when an individual believes irrational falsities that have nothing to do with what anyone else believes, it is psychosis.

Once this paranoid worldview has been firmly established as a belief system, it becomes the means by which all perceptions and experiences are perceived and interpreted; and thus experience takes on the appearance of supporting this belief system, everything only being analyzed in terms of its ideas.

I’m not too sure I agree with him that "when a culture at large believes irrational falsities, it is not psychosis", although he certainly knows a lot more about it than I do. IMO, having a lot of people invested in an irrational falsity doesn’t somehow magically make it more healthy.

sschoice

(Quotes are from Amie’s well-written post above)

According to a Senate Democratic aide, responding to concerns that birth control is not specifically called-out in the amendment, if individual drugs or "even categories of drugs" were listed, "we would have seen amendments filed on each one (or each category). I trust Sebelius [Kathleen Sebelius, head of HHS] to do the right thing with respect to covering birth control."

Cool. Good deal for those of us who will likely have hormonal birth control covered for the next few years, at least, but doesn’t this set up the potential for future HHS directors, perhaps under Republican administrations, to restrict or allow insurance companies to not cover drugs used for birth control? As much as we want to be sensitive to the needs of relatively poor women and families to have access to birth control, we should be sensitive to the issue becoming even more of a polarized political football game. Young and poor people seem to lose, the more the movement goes in that direction.

Putting control of "drugs or categories of drugs" which insurance companies would have to cover into the hands of a single appointed official, appointed by an administration elected by a partisan political process (the Presidential election cycle) would seem to be going a little further down that path, though we may not see much discussion about this until 3, or 7, or 11 years from now, closer to the next Presidential election or the one after that, or after that. It may be be better for birth control coverage to be explicitly mentioned, even if it’s done so in terms that aren’t everything we’d want it to be, to set a precedent for whatever support can be given to it with the momentum that exists now for it, than to leave it up even more to the outcome of Presidential elections we’ll see 3, or 7, or 11 years from now.

It might not have been politically possible to include language in this amendment for birth control coverage, but if it were done with any sort of compromise language, the current administration might have to take some responsibility for what might be less-than-idealistic language regarding birth control, and one wonders if they’d really want to be on the record as having done that.

Something like this would have likely happened if the Clinton administration had sought over-the-counter (OTC) approval of the emergency contraceptive drug PREVEN in the late 90s. PREVEN was approved by the FDA for prescription use in 1998, and there had been muted discussion before that about seeking OTC approval. If OTC approval of PREVEN had happened during the Clinton administration, there likely would have been anti-choice pressure and compromises like occured in the FDA and the Bush administration when Plan B was finally approved for OTC use. It would have been politically very difficult to do, if not impossible (and it’s hard to imagine the Clinton administration advocating OTC access at all, especially for all ages, after firing Surgeon General Joycelyn Elders and during the middle of the Lewinsky scandal investigation/inquisition), but if successful — even with age restrictions — it would have given us OTC access to EC eight years before Plan B’s 2006 approval, and if unsuccessful it’s hard to imagine PREVEN not being approved for prescription use as it was. Think it’s a good thing that people don’t remember the Clinton administration for trying to do any of that?

If you think that’s a digression, sorry, back to the present…

A senate aide quoted as a source in this study, responding to concerns about a future administration’s appointees taking a different position, said this:

In defining the essential health benefits, the Secretary must take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

So maybe in future administrations we’ll see restrictions proposed for birth control, allowing it’s use in broad terms if the woman’s health would be impaired otherwise, similar to how abortion is allowed under restrictive laws, where the woman’s health would be endangered? If so, and if an appointed official is in charge of this, they’d be able to do so with little the electorate could do about it until the next Presidential election, much like the FDA’s approval of Plan B for OTC use with restrictions under the Bush administration. Public comment to the FDA was solicited while OTC approval of Plan B was considered, but nonelected officials are not likely going to be as responsive and accountable to public comment, lobbying, letter-writing, etc, as elected officials would be.

The terms of restricting birth control coverage in the future along these lines would probably be very broad, enough to allow most adult women with significant education and resources and providers willing to prescribe to meet these restrictions, but obviously on the other side of the same lines there would be younger, poorer, and less educated women who would not be so able to overcome those restrictions, even if the terms don’t explicitly restrict them by name from coverage. It might be done simply by referring to concepts like those quoted above, "the health care needs of diverse segments of the population" and how it might be for their own good that some restrictions (maybe phrased as if it’s a benefit, like "informed consent") be encouraged or required.

If birth control is not spelled out as "covered" and if not being mentioned as "covered" matters, one should maybe not count on it being covered for long, and that this sets precedent for how it will be more of an issue in the future than it is now.

Just nobody please freaking tell us if this happens that this is going to lead to birth control "bans" any more than anti-choice, anti-abortion legislation is going to "ban" abortion. It would restrict access to young women (older minors in particular), and poorer and less educated women. Other women — most women — would find little restriction, at least little that they couldn’t accomodate, as is the case for most women seeking elective abortion under the variety of restrictive laws now in place. If we see campaign rhetoric that "bans" are threatened, we’ll quote the words we’re writing now and the experience of the effects of anti-choice legislation that we know better.